R-6604 PERMIT R_ 660
4 .
APPLICATION FOR CITY of CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/OO/ , RESIDENTIAL — COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA -
n /� YES El M yes—I understand thw at a Class A
NAME /r /\ root assembly is required .
NO Initial - I.C.B.O.
ADDRESS �- EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRAC O ' .�
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS - TYPE OF ROOF COVERING
CIN 8 ZIP �7N Al i� 9U/ /:; EXISTING �(_�
PHONE aSOf -6aLJ BUILT-UP I F,I u❑ I
LICENSE (�YASPHALT iINdtA 1 4 1999-]
NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provolone of Chapter a(commencing with Section WOOD S AK ES
7000)of ovoion 3 of the Business anal Professions Code,end my,Ilconse Ia In nue force and [t�'
effect.
/ 712 GDO WOOD SHINGLE
Lkenee/Cls—re , Lk.Number �/� 7
Deis /4L -Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION .PROPOSED
I hereby afflrm that I am exempt from the Contractors I-cense Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a penult to
construct,alter,Improve,demolish,or repair any structure,prior to He Issuance,also requires the BUILT-UP ROOF ❑
applicant for such Permit to file a dgned statement that he Is licensed pursuant to the provelons
• of the Contractors Ucense Law(Chapter a(wmmendnp wkh Sedlon Ins of virion 3 of the
Butlneee and Professions Code)or that he o exempt therefrom a�the heel or the off
ASPHALT SHINGLES if(7�r
wemptkn.Any,vloletkn of Section 7031.5 by any applicant for a psi sublease eeppnken
e civil penally of net mor an Ove hundred dollars(000).):
.pl,ee owner aft Try,«my, employees wltn wages as Qm neetlon,will do WOOD SHAKES ❑
the wast,arW the re le not Intended or offered for eels(Sec. an
antl Prates.
.alone Code:Th iractore Ucerae law does not apply an ow who bullde« WOOD SHINGLES ❑
Mprows tier end who dose such work him II or Ihroug his
e,provided Met
such Impr rib we net Intended or offered b.If, r, tlinp or Improwmenl
bsod wn one year of completion,the owner- will He, of proving that he did OTHER(SPECIFY) ❑
not bund rove for purpose of sa ).
❑I,en oma the property max siwlyco rsctlrp with licensed co am to construct
the protect(Bac. ,Bodo entlP adorns erne Contractors License Law
not PROVIDE LC.B.O.REPORT NO.
apply to en owner props Wlltlso mp—e tle,rwn,ard wtc conVacts for such protects '
with a contractcre) n pursuant tot Conirectore License Lew.
❑I em exemptu S.
B It P.O.for this reason PROVIDE MFGR.INSTALLATION SPECS.
Omer - Date
ATIO APPLICATION DATE VALUATION PERMIT FEE
' WORKER'S IbMPENSATION DECLARATION .
heroby affirm once penally of Pw r one of the following Oederatlon:
❑I have and Mn me aln a CerlHkete of Consent to self-Insure for Workary Cornpenaatbn, Building
as providetl for by Section 3700 of the Leber Code,for the performance of the nark for which this /'�
permit olssued. � � OV v- S61SR11
RlQ1 neve end will melnbin Workeri Compeneetlon Ineurence,ae required by section 3700 0l
IheA9bor Cade,for the performance of the work for which this permit Is Issued.My Worker's �Z —f d n
Compeneatlo�rraAe tamer nal Policy number are: �Je TotaVVl
Carrier CLil E- �Gt,lfll� pocky Na./4069x%/ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WDRKERS'
COMPENSATION INSURANCE N.C.0 a
(This section need not be completed It the permit b for one hundred dollars(Mo)or lose.) - Q
1 certify that In the performance of the work for which this permit is Issued, shell not employ
any person In any manner so as to become subject to the Workers'Cornpensanon Laws of call- All roofs shall be inspected prior to any roofing material being
romna. installed. If a roof is installed without first obtaining an
Date - Applicant Inspecllon,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Cengkate of Exemption,you should become Applicant understands will I n
subject to the Workers'CompenarnIon provisions of the Labor Code,you must forthwith comply pY'canunerss anComply Y with all on point
with such provisions or this permit shall be creamed revoked. source regulations.
I certify that I have resit this application and stab that the above Informetlon is correct.I agree
to comply with an city and county ordinances and state laws relating to bulidingwnstructbnend All ro coverings to be class or better. '
hereby authorize repreaentadwa of this city to enter upon the above-mentioned property for In-
spwiagrpoeae.
(We)el agree to saw,Indemnify and keep harmless tins cry of Cuperikcegelnet Ilebllflbe,
. w �!
Judgments, eb and expenses which may In any way acane against sad Ciry In ran arquence
N the rantln of this permit. SIGNATURE OFA PLICA DATE
PRE•INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. - DATE - INSP. DATE
. TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
i
•; CITY OF CUPERTINO - BUILDING DEPARTMENT
RE-ROOFING POLICY
1. Prior to permit issuance, you must agree to comply with U.B.C. standards and
Manufacturers specs on re-roofing.
2. New roof coverings shall not be applied without first obtaining all inspections and written
Approval from the building inspector. A final inspection and approval shall be obtained
from the building inspector when the re-roofing is completed.
3. All types of roofs shall be inspected prior to any roof being installed.
4. In order to receive a final, ou must complete steps 1,2, and 3.
Y P P
1. Pre-inspection or tear-off approval
2. In-progress inspection approval
3. Final inspection approval
a. Operable smoke detector verification
5. If plywood is installed, a plywood nail inspection is required.
• 6. If any roof is applied without first obtaining an inspection, you will be required to remove
all new material down to the sheating and a building inspector will inspect all sheating at
that time.
IMPORTANT:
1. Flat roofs must have a '/4" per foot slope, or demonstrate that there is no ponding.
2. I.C.B.O. reports are required to be on the job site at the time of inspection. If you do not
have one, contact the building department.
WE UNDERSTAND THE ABOVE POLICY ON RE-ROOFING AND WILL COMPLY
WITH THE POLICY. (�
HOMEOWNER'S NAME: NA/YI E.5iPrS
W
ADDRESS:
RE-ROOFING COMPANY NAME: iZ 0W/&
APPLICANT'S SIGNATURE:
• CITY OF CUPERTINO
BUILDING DEPARTMENT
Re-roogwinword